The injury/incident form is complex and presumes much information is on hand within the first moments after an incident. This may not always be the case. The time-sensitive information is captured in Section 1. WHO, WHAT and WHERE. The FHSSO and EHS can start their processes with this information and follow up as needed.
It is expected that the supervisor will continue to follow up (accident investigation, lost time, find root causes, devise a corrective action plan etc) after each updated submission of this form.
The report is divided into header section, Section 1 and Section 2.
- This section is to be filled by the injured worker, a witness or the supervisor. It must be complete.
- The header section asks you to determine if there was an injury or not. Check the appropriate box.
- If there was no injury, check hazardous situation.
- If there was an injury, check the INJURY box.
- First aid is selected if a first aider was called or first aid was applied.
- Healthcare is selected if:
- the person visited emergency, urgent care, walk-in clinic, their own physician or attended employee health services for the host hospital
- Lost time is selected if the person had to miss work as a result of the injury.
- No First Aid is selected if no treatment was applied.
Information of person who was injured
- to be completed by any person involved with the incident who would be able to answer the questions.
- If a learner, list the learner program as Department/Faculty/Unit
- the contact number is the contact for the injured person
- 'occupation' also applies to the learner placement activities.
- 'affiliation' for other may be contractor, visitor, or 'learner'
- select the appropriate UNION/EMPLOYEE GROUP and add the graduate student or undergraduate student associations if applicable under 'other'.
Description of Incident, Injury, Hazard
- building and room number are important, if in corridor or washroom or outside, detail this in the description of the incident.
- provide a very detailed description of what happened just before the incident, what occurred during the incident and if any environmental factors, items or people may have contributed to the incident
- provide recommendations on how this could have been avoided in part 2 of this question
- complete the rest of this section and attached extra information if necessary
Area of Injury
- Select the area of injury
- if there was an contact or inhalation exposure, select 'other' and describe type of exposure
Reason for Report
- select the applicable reasons for reporting
- medical symptoms may include seizure, dizziness, confusion, any respiratory, cardiac, neurological or gastrointestinal events that aren't otherwise captured elsewhere
- if the injured person saw a physician, please complete this part
- This section is to be completed by the supervisor.
Lost Time Incident Only
- complete this section ONLY if the worker had to take time off of their shift or work period
- this section will likely be unfilled because the report must be submitted with 24 hours of the incident and details of time off after the incident will not have occurred at this time.
- if the report is being filed late, and this information is known, please provide it
- If a worker does not need time of but then subsequently does please contact FHSSO immediately so we may follow up.
- if you need assistance with this section, contact email@example.com
- select all the check boxes that apply to this incident
- if there is a contributing factor that you believe is not captured, please select 'other' and provide details
- In addition to the checklist question: this part presumes that the supervisor has completed their investigation and has determined the cause
- if not known at the time of the incident, submit the report with this section blank, then perform you follow up and re-submit the edited form
- details of property damage - please complete section within the 24 hour window so that a property insurance claim can be initiated
- Please check all boxes that apply.
- regardless of the boxes checked, please provide details of that corrective measure i.e. the type of training provided, how it was provided or a fix to a work area or a fix to a piece of equipment, or cleaning up clutter or reorganization of the work area
- ensure that there is a person responsible for implementing that corrective measure and provide the date it was completed
- Please obtain all signatures
- you may submit the form at any time without signatures, however you must submit signatures within a reasonable amount of time